Healthcare Provider Details

I. General information

NPI: 1619825379
Provider Name (Legal Business Name): TASHYKA JUSSOME
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2026
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 EDUCATION AVE
PUNTA GORDA FL
33950-6222
US

IV. Provider business mailing address

3113 4TH ST SW
LEHIGH ACRES FL
33976-2433
US

V. Phone/Fax

Practice location:
  • Phone: 941-575-0222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11046166
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: